About Fallon Health:
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit www.fallonhealth.org.
Brief summary of purpose:
The Medical Claims Reviewer is responsible for all aspects of medical claims review including: determining the appropriateness of service, setting, service billing code, eligible benefits, contractual agreement, authorization and claims payment mediation, negotiation and adjudication. Processes complex claims and ensures correct payment of authorized claims following established protocols. Ensures compliance with contract administration, and service level requirements through claim reviews and client appeals. This position will work with other departments, project teams and committees as needed to resolve issues and contribute to policy and procedural improvements. This position will advise and make recommendations to Medical Review and Corporate Leadership.
Primary Job Responsibilities (Include duties that represent 5% or more of employee’s time)
Bachelors' Degree in Business and/or Nursing preferred
Required to possess CPC (Certified Professional Coder), “H” (Hospital) Certification, CCS (Certified Coding Specialist) or CCS-P (Certified Coding Specialist Physician-Based)
Clinical practice experience in an acute care setting preferred.
Claims auditing/processing experience and decision making based on analysis and problem solving
Ability to communicate complex issues
Ability to collaborate with internal and external customers
Knowledge of Fallon Health policies and procedures or equivalent experience
Solid working knowledge of CPT, ICD-10, HCPCS coding guidelines, and medical terminology
Understanding of medical billing (CMS1500/UB04)
Strong analytical ability and communication skills
MS Office and general PC skills
Excellent organizational skills
Must possess the ability to prioritize tasks and follow through to completion
QNXT experience desirable